|Year : 2010 | Volume
| Issue : 1 | Page : 7-16
Childhood morbidity, household practices and health care seeking for sick children in a tribal district of Maharashtra, India
AR Dongre1, PR Deshmukh2, BS Garg2
1 Sri Manakula Vinayagar Medical College and Hospital, Pondicherry, India
2 Dr. Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sewagram, India
|Date of Web Publication||31-Jan-2012|
P R Deshmukh
Dr. Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sewagram - 442 102
Objectives: To find out the magnitude of childhood morbidities, health care seeking behavior and explore the status of 'some desired practices' at household level during episodes of illness in two tribal blocks of Chandrapur district. Materials and Methods: The present explanatory mixed-method design of quantitative (survey) and qualitative (focus group discussions, FGDs )methods was undertaken in nine Primary health centers of Warora and Bhadrawati blocks in Chandrapur district. The information of 2,700 under-five children on morbidity, health care seeking behavior and some desired practices at household level was collected by paying home visits and using pre-designed and pre-tested questionnaire. The data was entered and analyzed by using SPSS 12.0.1 and C sample program of epi_info (version 6.04d) software package. The conventional content analysis of FGD data was undertaken. Results: The prevalence of morbidities was high among newborns and children. About 1,811 (67%) children had at least one of the morbidities. Private health care providers and village level faith healers were preferred for seeking treatment of newborn danger sings and childhood morbidities. The status of some desired household practices such as frequent feeding and giving extra fluid to drink during episodes of illness was poor. Conclusions: In conclusion, considering high prevalence of child morbidities and poor status of some desired household practices of caregivers at household level for sick children, household and community IMNCI strategy needs to be implemented to promote child health and nutrition. Apart from this, health care delivery at village level should be strengthened.
Keywords: Child survival, community practices, household practices, IMCI, IMNCI, tribal health
|How to cite this article:|
Dongre A R, Deshmukh P R, Garg B S. Childhood morbidity, household practices and health care seeking for sick children in a tribal district of Maharashtra, India. Indian J Med Sci 2010;64:7-16
|How to cite this URL:|
Dongre A R, Deshmukh P R, Garg B S. Childhood morbidity, household practices and health care seeking for sick children in a tribal district of Maharashtra, India. Indian J Med Sci [serial online] 2010 [cited 2013 Jun 19];64:7-16. Available from: http://www.indianjmedsci.org/text.asp?2010/64/1/7/92482
| ¤ Introduction|| |
Deaths in children under five years of age continue to account for a large proportion of the global burden of disease. Five primary causes of illness - pneumonia, diarrhea, malaria, measles and malnutrition - account for over 70% of child deaths.  It has been agreed that improving the quality of care at health facilities through training of health workers and improvement of health services alone would not be sufficient to reduce child mortality and morbidity.  Community participation, sustained links between the communities and health facilities, timely health care seeking and improved care of sick child at household level would help to reduce infant morbidity and mortality.  Household and Community Integrated Management of Childhood Illnesses (HH/C IMCI) strategy emphasized promotion of 'some desired practices' at household and community level for sick children.  However, little is known about the status of these desired household practices during the episodes of illness. This information is useful for planning services, capacity building of field staff and health education of local community. Hence, the present study has been undertaken to find out the status of 'some desired practices' at household level during episodes of illness and health care seeking behavior of mothers in two rural blocks of Chandrapur district.
| ¤ Materials and Methods|| |
Study setting and area
The present explanatory mixed-method design of quantitative (survey) and qualitative (focus group discussions, FGDs)  methods was undertaken in all nine primary health centers (PHCs) in Warora and Bhadrawati blocks of Chandrapur district. The total population of these two blocks was 2,19,615. The district is located in backward region of east Maharashtra, which is known for natural resources like coal mines, limestone and iron and its 56% of land is covered by the forests. The district had high under-five mortality of 137 per 1000 live births. 
Pre survey qualitative assessment
To begin with, we preferred to explore the various local terms for childhood disease symptoms, danger signs and common household practices during the episodes of illnesses as our pre-understanding on underlying dynamics in study area was limited. The free listing exercise was undertaken with purposively selected key informants (n=10) for enlisting local terms and phraseology for disease conditions. The findings of free list exercise  and UNICEF multiple indicator cluster survey (MICS) questionnaire  for under-five children was used for developing locally relevant questionnaire for the present study.
Quantitative assessment (survey)
A two-stage cluster sampling was adopted for the present survey. At first stage, clusters were selected by population proportional to size (PPS) method from the list of villages and at the second stage children (zero-five years) were identified from selected cluster by using 'random walk' method. Total 270 clusters were selected from nine PHCs in two blocks (30 clusters in each PHC). In total 2700 children i.e. a quota of 10 children (zero-five years) from each cluster were selected until the pre-determined study subjects were covered. This sample size was adequate at 50% prevalence of childhood morbidities, alpha of 5 and 3% precision with design effect of two and 20% of non-response. A team of trained social workers (Masters in social work with five years of field experience) paid house-to-house visit and after obtaining written consent, interviewed the mothers for the youngest child in the family by using the above mentioned pre-designed and pre-tested questionnaire. Two clusters were inaccessible and the survey supervisor replaced it with two others clusters of similar characteristics in same area. The structured questionnaire covered information on socio-demographic information, presence of newborn danger signs, childhood morbidities, and treatment seeking behaviors.
Mothers of children 0-11 months were asked to recall the presence of newborn danger signs during newborn period and health care seeking for it. Mothers of children more than one year of age were enquired about symptom specific self-reported morbidities such as fever, cough, difficult breathing and measles during the preceding two weeks and health care seeking for it. Health care seeking was defined as any attempt by the mother to obtain an expert opinion from a biomedical health care provider outside the home during the baby's illness.  Information on 'some desired practices' like continued breastfeeding, increased feeding frequency, giving extra food to the baby, keeping the baby warm and the use of safe home remedies was collected for all children who were reported to have been ill. Socio-economic status was assessed by type of ration card, which is distributed by Government of Maharashtra under Public distribution system. Five percent of questionnaires were re-checked to ensure quality of data. The study was undertaken during December 2008 to January 2009. Ethical principles were adhered.
Post survey qualitative research
After survey, focus group discussions (FGDs) were undertaken with the different groups of mothers to explore their perceptions, their current household level practices for sick children, and health care seeking for it. After survey, a meeting with the field interviewers was arranged and a participatory guideline for FGD was developed. After obtaining informed consent, FGDs were undertaken with the group (six to eight participants) of purposively selected mothers in reproductive age group (15-49 years) from different socio-economic strata of the surveyed area, who were willing to participate and talk freely. The trained social worker who has five years of experience in collecting qualitative data, moderated FGDs sessions using semi-structured guidelines and note taker recorded it. After ten FGDs, we reached a saturation point, where it stopped yielding any new information.
The data was entered and analyzed by using SPSS 12.0.1 software (SPSS Inc., Chicago, Illinois, USA) package and C sample program of epi_info (version 6.04d) software package. 95% confidence intervals (CI) were adjusted for design effect as the data was collected by cluster sampling technique. The conventional content analysis of textual FGD data was independently undertaken by two trained public health specialists (first and second author) to increase the trustworthiness of results. 
| ¤ Results|| |
Overall, the average age of the responding mother was 24.9 years (th + 0.06 SE) and they had 9.5 years (th + 0.07 SE) of school education. About 1,811 (67%) under-five children had at least one of the morbidities. The prevalence of morbidities varied significantly with age. It was lowest (51.1%; 95% CI, 45.7 -56.5%) in 0-11 months age group while it was highest (77.8%; 95%CI; 72.8 -82.1%) in 12-23 months age group (P=0.001) [Table 1].
|Table 1: Socio-demographic information of the respondents (mothers of 0-5 years)|
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Newborn danger signs and health care seeking
Out of 696 newborn, 265 (38.1%), 92 (13.2%) and 103 (14.8%) were reported to have fever, difficult breathing and poor sucking, respectively, in newborn period. Nine (1.3%) and 11 (1.6%) newborns had convulsion and multiple boils over body respectively. Thirty eight (5.5%) newborns had low body temperature and 11 (1.6%) babies had pus discharge from umbilicus. Overall, 356 (51.1%) newborns had at least one of the newborn danger signs. For all newborn danger signs, majority of the mothers accessed private doctors for treatment. Notably, 36 (35%), 32 (34.8%), 3 (27.3%) and 15 (5.7%) mothers went to faith healers (Vaidu) for treatment of poor sucking, difficult breathing, boils over body and fever respectively. Only five children with poor sucking and fever each and one child with difficult breathing were taken to village level Auxiliary Nurse Midwife (ANM) or Anganwadi workers (AWW) [Table 2].
Child morbidity and health care seeking
Out of 2004 children (> 1 year of age), 1142 (55.5%), 992 (49.5%) and 307 (15.3%) had history of cough, fever and difficult breathing in two weeks preceding the survey respectively. About 231 (11.5%), 68(3.4%), 24(1.2%) children had diarrhea, measles and dysentery respectively. Overall, 1455 (72.6%) children had history of at least one of the childhood morbidities. Out of 1142 children who had cough, 711 (62.3%), 276 (24.2%), 31 (2.7%) and 72 (6.3%) children were taken to private doctors, government doctors, ANM/AWW and faith healers respectively. Among 992 children who had fever, 649 (65.4%), 247(24.9%), 45 (4.5%) and 29 (2.9%) were taken to the private doctors, government doctors, faith healers and ANM/AWW respectively. For other morbidities, such as difficulty in breathing, diarrhea, dysentery and measles, majority of sick children were taken to private doctors for treatment. Notably, out of 68 children who had measles, 15 (22.1%) were taken to faith healers for treatment. Only 52 (4.6%) children with cough, 22 (2.2%) children with fever and four children (1.3%) with difficult breathing received home treatment [Table 3].
Household practices during illness
[Table 4] and [Table 5] explored the status of some desired practices at household level during the episodes of illness. Out of 1811 sick children, 1264 (69.7%) were continued breastfeeding. About 260 (73.0%; 95%CI, 65.7 -79.2%) infants, 378 (74.8%; 95%CI, 68.9-79.9%) children of 12-23 months and even 626 (65.9%; 95%CI, 61.4 - 70.1%) children more than two years were continued breastfeeding during the period of illness (P=0.001). Notably, 861 (73.2%; 95%CI, 69.3-76.6%) sick children of working mothers were continued breastfeeding (P=0.001). There was no sex, education, socio-economic and caste differentials of the desired breastfeeding practice. Only 934 (51.5%) sick children were given increased frequency of feeding. Significantly more sick infants, 203 (57.0%; 95%CI, 49.3-64.3%) and 288 children of 12-23 months (57.0%; 95%CI, 50.6 -63.2%) were given increased feeding than 443 (46.6%; 95%CI, 42.0- 51.2%) children more than two years (P=0.001). The increased feeding frequency was significantly lower among sick children of the scheduled tribes/nomadic tribes (ST/NT) (53.4%; 95%CI, 47.7-59.0%) and the other backward class (OBC) (47.5%; 95%CI. 42.9-52.1%) caste (P=0.001). There was no sex, education, socio-economic status and occupation differentials in increased feeding practice. Out of 1811 sick children, 891 (49.2%) were given extra fluid and 1182 (65.3%) were kept warm. Significantly more children of 12-23 months (71.7%; 95%CI, 65.6 -77.0%) and more than two years (72.1%; 95%CI, 67.7 - 76.0%) were given safe home remedies such as honey, tulsi, ginger, herbal tea (P=0.013). There were no other socio-demographic differentials for the last two desired household practices.
|Table 4: Feeding practices during the episodes of illness among mothers with child morbidities|
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|Table 5: Practices related to care and safe home remedy during the episodes of illness|
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Findings from FGDs
According to the participants of focus group discussions, hasri yene or chilka basne (poor sucking), loose stool, dhapne or dabba (difficult breathing), excess cry, galyashi yene (boils in throat), kamshakti (low birth weight), zatke yene (convulsion) and zapde yene (lethargy/unconsciousness) were newborn danger signs. In the presence of these danger signs, caregivers initially prefer home treatment for one day. Village level faith healer (vaidu) is often consulted for sanctified water, threads and other local treatment. For treatment of newborn danger signs, private health care providers are preferred as they are perceived as specialist of their subject. The private doctors are available in emergency and their treatment in the form of injection and saline was said to give rapid relief. Although their medicines or treatment are expensive, repeated follow up is not required. On the other hand, the government health providers are not available in emergency and if available they do not pay much attention to the patient, their medicines are cheap and offers no relief. According to few respondents, the frequency of feeding is reduced among children with diarrhea and only dry food items are given to eat. This practice was said to reduce stress on baby's stomach and the frequency of loose stool. Few mothers responded that children had reduced appetite and eat less during the period of illness. As a precaution for disease prevention, oil-containing food items and sour food items are avoided in baby's diet as it was said to lead difficulty in breathing, jaundice and cough. Hot foods (such as papaya, egg, apple, chikku) and cold foods (such as curd, banana, guava, pomegranate, lemon and custard apple) are avoided in babies' diet. Although mothers knew about safe home remedy for cough such as honey, tulsi, ginger, herbal tea etc, nowadays most of them immediately access health care and prefer to take syrup, injections and tablets. The left over medicines after the treatment of illness is kept and was used during the next episodes before seeking medical care.
| ¤ Discussion|| |
Our results found high prevalence of morbidities among newborns and children. Overall, 51.1% newborns had at least one newborn danger signs and 72.6% children had history of at least one of the childhood morbidities. Private doctors and village level faith healers were preferred for seeking treatment of newborn danger signs and childhood morbidities. The status of some desired practices such as frequent feeding and giving extra fluid to drink during episodes of illness was poor. In rural Bangladesh, the practices like discontinuing breastfeeding and reducing feeding frequency of sick children has been reported.  Our formative research explained the rationale behind the caregivers' practices at household level. Such formative explanation is required to study the actual practices of caregivers in order to form the basis for a child-care education program. 
In the present study, 13.2 and 14.8% newborns had difficult breathing and poor sucking respectively. About 1.3 and 5.5% newborns had convulsion and had low body temperature respectively. The private health care providers were preferred for treatment due to their better quality of services. In rural Wardha, 26.6 and 7.8% newborns were reported to have difficult breathing and poor sucking respectively. Two percent newborns had history of convulsion and low body temperature. Notably, mothers of rural Wardha also preferred expensive services of private providers, as the doctors and nurses were available for prompt health care to sick baby. 
We found that 55.5, 49.5 and 15.3% children (more than one year) had history of cough, fever and difficult breathing in last 15 days respectively and 11.5, 3.4, 1.2% children had diarrhea, measles and dysentery in last 15 days respectively. Mishra et al. reported that 26.3% under five children were suffered from cough and cold, 22% from diarrhea and 3.6% from pneumonia in rural Allahabad.  Ray et al. reported that 58.2 and 22.2% under five children suffered from ARI and diarrhea respectively in rural West Bengal.  Another study from rural Meerut district of Uttar Pradesh, 42.3% under-five children were suffered from acute respiratory infection.  According to National Family Health Survey-III (NFHS-III) in India, 15 and 9% under-three children were reported to have been sick due to fever and diarrhea respectively.  This information showing high prevalence of childhood morbidities with inter-state variations is crucial for need based and area specific prioritization and policy formulation during implementation of child survival program.
Owing to the doubtful efficacy of treatment they receive from the government health care providers, the poor rural mothers preferred to access private doctors, although, the quality of care and qualification of these private providers can be questioned. The objective verification of qualification of private providers was not feasible in the present study. During the episodes of the illness, 73% infants and 74.8% children of 12-23 months were continued breastfeeding, only 51.5 and 49.2% sick children received increased feeding frequency and extra fluid respectively and 65.3% sick children were kept warm. However, 70.4% sick children were given safe home remedies like herbal tea, honey, ginger etc for relief of cough. Hence, promotion of desired practices during the episodes of illness is crucial for prevention of mortality. In order to strengthen public health facilities, the Government of India has undertaken nationwide National Rural Health Mission, which intends to implement Integrated Management of Neonatal and Childhood Illnesses strategy through trained health care providers and ensure public-private partnership for health care delivery. 
Unfortunately, national health programs in India rely too heavily on curative approach and the health education efforts does not address the needs of the rural population.  Community mobilization and participatory, need based health education strategy based on local epidemiology and caregivers perspectives could improve health care seeking for newborn danger signs in rural Wardha.  Hence, along with the initial two components of IMCI strategy (improving the skills of health workers and improving health system), the third component of IMCI strategy i.e. household and community IMCI (HH/C IMCI) strategy should be implemented through community participation. Notably, very few mothers of sick children consulted Anganwadi workers and Auxiliary Nurse Midwives. The role of Anganwadi workers and Accredited Social Health Activist (ASHA, community level female health worker) can be strengthened under household and community IMNCI to promote desired practices at household level and bridge gaps in household to hospital care of continuum.
In conclusion, considering the high prevalence of child morbidities and poor status of 'some desired practices' of caregivers at household level for sick children, HH/C IMCI strategy needs to be implemented to promote child health and nutrition. Apart from this, health care delivery at village level should be strengthened.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]